Arnold School of Public Health

PUBH 102: INTRODUCTION TO PUBLIC HEALTH

UNNATURAL CAUSES: “In Sickness and In Wealth”

What to Look for….

Focus of this episode: How does the distribution of power, wealth and resources shape
opportunities for health?

General Info:
 30 in life expectancy
o Shorter and sicker lives than most industrialized nations
o Bottom of list of economically developed countries
 2 trillion per year on medical care
 Health Care coverage
 Infant mortality
 Social Determinants of Health
o Social class is the most important one
 Accumulation and how to deal with them – due to social class
 Identical Twins
o Differences in health when diverged in life
 Excess death
o Death that should not have happened
 Be able to predict death, the difference between the actual and predicted
is excess death
 Can depend on neighborhood
 College graduates live 2.5x longer than high school graduates
o Education is a way to move up the health gradient
o Can you afford degree?
 35% increase
 Growing up in poverty can lead to stress in children and impinge development

 What did the Whitehall study reveal about the connection between health and wealth?
a. What is the wealth-health gradient?

 1970s Whitehall Studies

o Sir Michael Marmot
 Epidemiologist
 How Social Influences affect disease
 Looked at people’s employment grade in the hierarchy
 Charted the health of 29,000 British Civil Servants
o The belief: the higher grade of employment = higher risk of heart disease
o Actual: the lower grade of employment = higher risk of heart disease
 Also true for every major cause of death
 Health rates and illness correlated to status
o even after controlling for unhealthy behaviors
 Even USA has social gradient like in Britian
 In America
 o Wealth-health gradient:
 71% of affluent Americans report good to excellent health
 >$80k
 47%
 $20-40k
 56%
 $40-60k
 62%
 $60-80k
 37% of poor Americans
 <$20k
o Reverse slope of chronic disease
 Heart disease, stroke, diabetes rates increase with decreasing income

 Dr. David Williams says: “Stress helps motivate us. In our society today everybody
experiences stress. The person who has no stress is a person who is dead.”
a) Describe the body’s stress (fight-or-flight) response.
 Feeling threatened or not having control over our lives
(1) Biological reaction kicks in when the brain perceives a threat
(a) Signals adrenal glands to release stress hormones
(i) Ex. Cortisol
1. Put body on alert
2. Enhance immune respond
3. Helps reestablish energy supplies
(ii) They flood bloodstream with glucose
(iii) Increase heart rate
(iv) Raise blood pressure
b) How is chronic stress different?
 High stress over a long period of time
 Cortisol keeps being produced
(1) Can inhibit memory
(2) Cause areas of the brain to shrink
c) How might chronic stress increase the risk of illness and disease?
 Excess cortisol/chronic stress can impair immune function
(1) The toll it takes on the body shows high rates of illness and disease
(2) Accelerated aging

 How do the lives of Jim Taylor, Tondra Young, Corey Anderson and Mary Turner
exemplify concepts like the wealth-health gradient and the importance of power and
control?
 Jim Taylor = CEO of Hospital – more power and control, earns well into 6 figures,
healthy at 60, lives in district 16 (high college graduates 63.8%, safe, low disease, life
expectancy = 79.3) power and control
 Tondra Young = lab manager – stressful job but less power and control, middle class,
went to college while working full time, bought a home, mortgage and student debt, lives
in district 24 (not many college graduates 15.4%, life expectancy = 75.3)
 Cory Anderson = lives in district 21 (life expectancy = 73.4 years) and has his whole life,
mother worked full time and paycheck was more than that (lost job, BP went up, Dr more
often, took a tole on mental and physical health), works full time with wife (48k ~ national
average) and they can’t really save, diagnosed with hypertension at 37 (along with 1/3 of
 district 21), Floor Technician at the University of Louisville Hospital – the control is very
limited
 Mary Turner = lives in district 5 (1/3 of residents haven’t received a high school diploma,
30% live at or below the poverty line, life expectancy is 69.8 years, 12% are unemployed
(double national average)), 49 years old, disabled husband, 3 children at home, you eat
what fits your budget, things get sparse towards the end of the month, Mary allows
herself one meal per day so her children can eat, she is unemployed now and volunteers
at the local history museum, had a heart attack several years ago, arthritis, vacation =
going to the park and watch the river, children don’t like to walk by themselves
a) What does comparing data maps of disease rates in the different Louisville
council districts reveal?
i) It shows where there are more affluent people living, towards the east, there are less
diseases and illnesses compared to that of the west.
ii) District 16 - east
(1) Life Expectancy = 79.3
(2) Education = 63.8% college graduates
iii) District 24 – middle east
(1) Life Expectancy = 75.3
(2) Education = 15.4% college graduates
iv) District 21 – middle west
(1) Life Expectancy = 73.4
v) District 5 - west
(1) Life Expectancy = 69.8
(2) Education = 1/3 of residence haven’t graduated from high school
b) What might explain observed differences?
i) The safety of the neighborhood
ii) Food deserts – not being able to afford healthy food or even access it
iii) Affordable housing

 Professor Leonard Syme defines control of destiny as the “ability to influence the
events that impinge on your life.” Why is this ability an important factor for health?
 Managing those stressors in your life can dictate health.
(1) Poor, job insecurity – decrease control over lives
 Those with low control over their lives (i.e. at work, the neighborhood you live in)
experience higher stress than those with more power over what they can control.
(1) This can cause health risks
 What stories from Corey Anderson’s life exemplify a high demand / low control job
and stressful home situation?
a. Floor Technician at the University of Louisville Hospital – the control is very limited
b. Respond to a lot of demands from above
 First told to clean patient rooms – but pulled to help with trash – pulled trash then
paged to go back to cleaning rooms
(1) Bounced around
c. 1/5 American Men work in a high demand, low control job
 More likely to experience high blood pressure at work
 And the levels don’t fall as much – even in sleep
d. Took a bus to Miami for vacation

 What stories from Jim Taylor’s life illustrate how wealth, power and status translate
into better health?
 a. Makes a lot of money
b. Able to choose where he lives – safe
c. Transportation is not an issue
d. Not huge demands outside of work
e. Ability to eat healthy – time, money, resources
f. Able to take a vacation and how to take it

 What did the Macaque monkey research teach primatologist Carol Shively about the
connections between power, subordination and health?
 Hierarchy
 A dominant animal has complete control over his life – can go where ever he
wants in the pen
(1) All the control he needs to create an optimal environment for himself
 Subordinate animals have almost no control of what happens to them
(1) They must be watching all the time
(a) High level of vigilance --- increase heart rate
(b) A state of chronic stress
(i) Higher levels of cortisol circulating in their blood
 Arteries of dominant and subordinate (same diet, same age)
(1) Dominant = healthy, large whole for blood to go through
(2) Subordinate = a larger buildup of plaque (atherosclerosis)
(a) Due to stress of social subordination
(b) At risk for heart attack

a. What parallels can we draw to human society?

 Psychologist Sheldon Cohen
(1) Tested humans for cortisol levels and compared the levels to their SES
(a) More education you have, income --- the less cortisol you release throughout
the day
(2) Tested effects of stress on body (immune system)
(a) Brought healthy people in and exposed them to a virus – drop in nostrils of
cold virus
(b) Those with less chronic stress caught fewer colds than those with chronic
stress
(3) Home ownership
(i) Did their parents own a home during their childhood? How many years
their parent owned their home?
(ii) Great predictor of if they get a cold or not

 Describe examples from the film that illustrate how racism imposes an additional
health burden on people of color.
 If you’re an African American – health outcomes will be worse than if you are white
(1) Higher rates of Hypertension, stroke, diabetes across social gradients
 Vigilance to be on constant guard takes its toll
(1) Makes people vulnerable to illness/disease
(a) Coronary Heart Disease
(2) 83,000 excess deaths per year in the African American community alone
 b. Give examples of both “everyday” racism (being treated unfairly) and “structural”
racism (access to resources, power, status and wealth) and describe how these
might affect health in different ways.
 “Everyday” -- Being followed around the store while buying things, woman grabbing
purse while walking onto the elevator
 “Structural” – largely left out of 20th century achievements until 1960s, economic
health is related to physical health, unequal distribution of resources

 What social changes were most responsible for the 30-year increase in American life
expectancy over the 20th century?
 Universal Education, better sanitation, 8-hour work day, income tax, GI Bill – homes
and education, advances in medicine
b. What policies does the film point to that might account for our low rank in recent
years compared to other countries?
 1980s – recession
(1) Government cut social programs
(2) Reduced taxes for the rich
(3) Consequences remain today
 The gap between the super-rich and the middle class keeps growing
 Wealth Inequality keeps soaring
 Most unequal of the rich democracies
(1) Poor and getting poorer, middle class are squeezed
(a) Health = wealth
 Over 1 trillion dollars lost in productivity from chronic illness and dependency
c. What characterizes the policies and priorities of countries that have better health
outcomes than we do?
 Guaranteed universal health care coverage, mandated 4-week vacations, payed
maternity leave
(1) France’s minimum wage is twice ours
(2) Ireland provides free college education
(3) Sweden family plan reduced childhood poverty to 4.2% compared to USA 21%
 Found ways to break the linkage from health to wealth
 Where wealth is equitably distributed, people are healthier